Parental approval is required for youth under age 18 to participate in 4-H Summer Camp activities. This form, along with the Michigan 4-H Member Enrollment ...
4-H SUMMER CAMP REGISTRATION FORM 4-H Summer Camp Dates: Mon, June, 26 – Wed, 28, 2017 *Counselors stay until June 29 Parental approval is required for youth under age 18 to participate in 4-H Summer Camp activities. This form, along with the Michigan 4-H Member Enrollment Form Authorization Form, must be completed and returned to the MSU Extension office before participation in this event. 4-H Sumer Camp Registration Period: March 6, 2017 – May 18, 2017 @ 4:30pm *Don’t wait to sign-up - Each county gets 13 spaces, first-come, first-served - Then campers go on a waiting list until May 1 to see if extra spaces are open.
COUNSELORS: Please complete online application at bit.ly/1LCuDBb by April 15, 2017 @ 4:30pm *If you are selected to serve as a counselor you will be asked to complete this registration form
Camp Age Requirements: 9-12 years old
Counselor Age Requirements: 15-19 years old
Full legal name ________________________________________________________________________ (Last)
(First)
(Middle)
Number of times you’ve attended this 4-H Summer Camp: _______ COUNTY Please check one: Alcona Alpena Montmorency Otsego Presque Isle Other:
STATUS Must check one: Camper – Not a 4-H member Camper – 4-H member; Number of years in 4-H: Approved 4-H Summer Camp Counselor Please check all that apply: Disability - wheelchair user Disability - physical (please indicate): Disability - learning or functional (please indicate): Special dietary needs (please indicate): T-SHIRT SIZE Please select one: Small Medium
Youth_____
Adult_____ Large X-Large
XX-Large XXX-Large
PAYMENT (Teen counselors DO NOT pay for camp) The full payment of $75.00 for 4-H members or $85.00 for non-members must be submitted with the registration form to the MSU Extension office. Please make your check or money order payable to: MSU In the event of cancellation after June 1, but prior to June 29 without same-gender replacement, a $37.50 fee will be assessed and the balance will be refunded. No Shows are not subject to a refund unless injury/illness prevents camper from attending in which case a 50% refund will be issued. FOR COUNTY MSU EXTENSION OFFICE USE ONLY: Date
Amount $
Receipt #
Camper #
MSU is an affirmative action/equal opportunity employer. Michigan State University Extension programs and materials are open to all without regard to race, color, national origin, gender, gender identity, religion, age, height, weight, disability, political beliefs, sexual orientation, marital status, family status or veteran status. Issued in furtherance of MSU Extension work, acts of May 8 and June 30, 1914, in cooperation with the U.S. Department of Agriculture. Dr. Jeff Dwyer, Director, MSU Extension, East Lansing, Michigan 48824. Page 1 of 4
SECTION 1 – PARENT/GUARDIAN CONSENT: I hereby grant permission for (print participant’s name)________________________________________ to participate in all educational and social activities of 4-H Summer Camp sponsored by Michigan State University Extension’s 4-H Youth Development Program. I understand that some sessions take field trips and that some sessions, and other recreation activities have special risks. I accept any risks associated with their assigned session(s) and recreational activities. I will make a note of any special needs or health concerns on this form. Name of Parent/Guardian (Please print): Signature of Parent or Guardian:
Date:
SECTION 2 – MEDICAL TREATMENT AUTHORIZATION: This section must be completed and signed by a parent or guardian for all youth participants before they can participate in this program. If this form is not completed, youth participants will not be allowed to participate. Please complete this form to give a medical facility permission to treat the participant for minor injuries or medical problems. In the event of serious injury or illness, the parent or person designated will be contacted. Treatment will proceed before contacting the parent or person designated only if the situation is urgent and does not permit delay. Participant’s full legal name: Birth date (MM/DD/YYYY):
Age:
Parent Phone (Day):
(Evening):
E-Mail (to be used for camp correspondence): Mailing Address: Primary Care Physician’s Name: Physician’s Address: Physician’s Phone:
HEALTH INSURANCE INFORMATION: Policy Holder’s Name: Relationship to Participant: Policy Holder’s Address: Page 2 of 4
*Attach photocopy of both sides of insurance card -OR- complete the insurance information below. Insurance Company Name: Insurance Company Address: Insurance company phone number: All Policy Numbers (please identify):
If you have HMO insurance, please list the emergency treatment authorization phone number:
Employer’s Name: Employers Address: Business Phone:
INFORMATION NEEDED ABOUT PARTICIPANT: Please circle yes or no. If yes, explain below or on another sheet if you need more room. Yes
No Does the participant have any chronic health problem or illness?
Yes
No Does he or she have any acute illness now?
Yes
No Has he or she been treated recently for a medical problem?
List any medications he or she is now taking for treatment of any medical problem.
Yes
No Does the participant have any allergies to medication or local anesthetics?
Yes
No Does he or she have any allergies?
Yes No Does the participant have any special needs that staff should be aware of in order to help make their camp experience a positive one?
Date of his or her last tetanus shot: Page 3 of 4
OFFICIAL AUTHORIZATION FOLLOWS: I (parent or legal guardian), ___________________________________________, recognize that while attending this program, medical treatment on an emergency basis may be necessary for my child, and I further recognize that MSU 4-H staff may be unable to contact me for my consent for emergency medical care. I do hereby consent in advance to such emergency care, including hospital care, as may be deemed necessary under the circumstances and to assume the expenses of such care. I also authorize the medical facility to release any and all information required to complete insurance claims and also authorize insurance payment directly to the medical facility. Signature of Parent or Guardian:
Date:
SECTION 3 – 4-H OVERNIGHT HOUSING PERMISSION: I understand that my child may be sharing lodging with an unrelated adult (21 or older) that has been through the MSU Extension Volunteer Selection Process and with at least one other young person. By signing this form I give my permission for my child to attend this event under these lodging conditions. Signature of Parent or Guardian:
Date:
SECTION 4 – MEDIA RELEASE: Participants are sometimes photographed and videotaped for use in MSU promotional and educational materials but are not identified by name in the materials. I authorize Michigan State University to record the image and voice of the subject named below and give MSU and all persons or entities acting pursuant to MSU’s permission or authority, all rights to use of these recorded images and voice. I understand that said images and/or voice will be used for educational, advertising and promotional purposes in all conventional and electronic media, including but not limited to the Internet and any future media. I also authorize the use of any printed material in connection therewith. I understand and agree that these images and recordings may be duplicated, distributed with or without charge, and/or altered in any form or manner without future or further compensation or liability, in perpetuity. Print Subject’s Name: Signature of Parent or Guardian:
Date:
Detailed camp information will be mailed to you after the June 1st Page 4 of 4
